MEDICARE: MRS. KELLY EATON MANNING RDH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	124Q00000X	Dental Hygienist	101165	NV

General Provider Information

NPI Number	:	1649326828
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. KELLY EATON MANNING RDH

Provider Business Mailing Address
First Line	:	10737 WOODLORE PL
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89144-5401
Country	:	US
Telephone Number	:	702-314-8670
Fax Number	:

Provider Business Practice Location Address
First Line	:	7520 W WASHINGTON AVE
Second Line	:	SUITE 120
City	:	LAS VEGAS
State	:	NV
Zip	:	89128-4330
Country	:	US
Telephone Number	:	702-363-1590
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/28/2007
Last Update Date	:	07/08/2007

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